May 14, 2013

Women have more options for breast cancer surgery

The Associated Press

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Rose Ragona is photographed in Chicago on May 1, 2013. Ragona was diagnosed with breast cancer and recently had a mastectomy where surgeons saved much of her skin and started reconstruction during the same surgery. Treating breast cancer almost always involves surgery, and for years the choice was just having the lump or the whole breast removed. Now, new approaches are dramatically changing the way these operations are done, giving women more options, faster treatment, smaller scars, fewer long-term side effects and better cosmetic results. (AP Photo/Carrie Antlfinger)

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Actress Angelina Jolie arrives for the British Gala premiere for the film 'Salt', at a central London cinema, in this Aug. 16, 2010 file photo. Jolie authored an op-ed for Tuesday’s May 14, 2013 New York Times where she writes that in April she finished three months of surgical procedures to remove both breasts as a preventive measure. She says she’s kept the process private but is writing about it now with hopes she can help other women. (AP Photo/Joel Ryan, File)

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Reconstruction can use tissue from the back or belly, or an implant. The first operation often is to place a tissue expander, a balloon-like device that's gradually inflated to stretch the remaining skin and make room for the implant. A few months later, a second surgery is done to remove the expander and place the implant. Once that heals, a third operation is done to make a new nipple, followed by tattooing to make an areola, the darkened ring around it.

The new trend is immediate reconstruction, with the first steps started at the time of the mastectomy, either to place a tissue expander or an implant. In some cases, the whole thing can be done in one operation.

Nationally, about 25 to 30 percent of women get immediate reconstruction. At the Mayo Clinic, about half do, and at Georgetown, it's about 80 percent.

Jolie wrote in an op-ed piece in the New York Times that she had tissue expanders and then implants placed nine weeks later. "There have been many advances in this procedure in the last few years, and the results can be beautiful," she wrote.

SPARING SKIN, NIPPLES

Doctors usually take the skin when they do a mastectomy to make sure they leave no cancer behind. But in the last decade they increasingly have left the skin in certain women with favorable tumor characteristics — and women having preventive mastectomies, such as Jolie. Attai compares it to removing the inside of an orange while leaving the peel intact.

"We have learned over time that you can save skin" in many patients, Willey said. "Every single study has shown that it's safe."

Now they're going the next step: preserving the nipple, which is even more at risk of being involved in cancer than the skin is. Only about 5 percent of women get this now, but eligibility could be expanded if it proves safe. The breast surgery society has a registry on nipple-sparing mastectomies that will track such women for 10 years.

"You really have to pick patients carefully," because no one wants to compromise cancer control for cosmetic reasons, Attai said.

"The preliminary data are that nipple-sparing is quite good," but studies haven't been long enough to know for sure, Willey said. "It makes a huge difference in the cosmetic outcome. That makes the woman's breast recognizable to her."

Dr. Judy Boughey, a breast surgeon at the Mayo Clinic, said the new approach even has swayed patients' treatment choices.

"We're seeing women choosing the more invasive surgery, choosing the mastectomy," because of doctors' willingness to spare skin and nipples, she said.

It helped persuade Rose Ragona, a 51-year-old operations supervisor at O'Hare Airport in Chicago. She had both breasts removed on April 19 with the most modern approach: Immediate reconstruction, with preservation of her skin and nipples.

"To wake up and just see your breasts there helped me immensely," she said.

She chose to have both breasts removed to avoid radiation and future worry.

"I felt it was a safer road to go," she said. "I can't live the rest of my life in fear. Every time there's a lump I'm going to worry."

FREEZING TUMORS

Attai, the California breast surgeon, is one of the researchers in a national study testing cryoablation. The technique uses a probe cooled with liquid nitrogen that turns tumors into ice balls of dead tissue that's gradually absorbed by the body. This has been done since 2004 for benign breast tumors and the clinical trial is aimed at seeing if it's safe for cancer treatment.

"The technology is amazing. This is done in the office under local anesthesia, a little skin puncture," Attai said.

In the study, women still have surgery at some point after the freezing treatment to make sure all the cancer is destroyed. If it proves safe and effective, it could eliminate surgery for certain cancer patients.

"I'd love to see the day when we can offer women with small breast tumors a completely non-operative approach, and I do think that's coming soon," Attai said.

 

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